6
African-American ParentsPerceptions of Partnership with their Childs Primary Care Provider Ivor B. Horn, MD, MPH, Stephanie J. Mitchell, PhD, Jill G. Joseph, MD, PhD, and Lawrence S. Wissow, MD, MPH Objective To identify family, provider, and healthcare setting characteristics associated with African-American parents’ perceptions of partnership with their child’s primary care provider. Study design Data were collected via a telephone survey of 425 African-American parents of 0- to 5-year-old children who had presented for a health visit 1 to 2 weeks earlier at participating pediatric primary care practices in Washington, DC. Parents’ perceptions of the level of partnership building by their child’s provider were assessed using the Street Provider Communication Style instrument. Results Multivariate logistic regression models indicated that, after adjusting for other family and provider/setting characteristics, parents seen in community health centers were more likely to report high partnership building compared with parents seen at private or hospital-based practices. Parents with at least a college education and those who described their child’s provider’s race as ‘‘other’’ were most likely to report moderate partnership building. Conclusions Future studies should examine elements of care delivery at community health centers that may lead to better partnerships between parents and providers in private and hospital- based practice settings. (J Pediatr 2011;159:262-7). M ounting research indicates that, compared with white children, African-American (AA) children experience poorer health outcomes and less parental satisfaction with pediatric primary care, even after adjusting for access-related factors such as insurance coverage. 1-3 For example, AA children visit the emergency department for asthma- related issues >3.5 times more often than white children. 4 Middle-income AA children also are less likely than their white coun- terparts to schedule appointments for routine care when they want them, 5 and less likely to be referred to a specialist by their health care provider. 3 Research in adult patients suggests that less participatory patient–provider communication is a modifiable contributor to racial health disparities. 6-8 Minority patients may not express their symptoms well because of language barriers, low health lit- eracy and educational attainment, and lack of self-efficacy regarding healthcare. 9 A provider may be less inclined to use a par- ticipatory communication style with minority patients if he or she holds racial biases or has limited awareness of cultural beliefs and expectations regarding disease and clinical care. 8 On the other hand, there is some evidence indicating that a participatory communication style contributes to improved health outcomes and, in turn, reduces health disparities among AA adults. 10 The few pediatric studies performed to date suggest that the quality of parent–provider communication contributes to minority children’s health outcomes through its influence on parents’ satisfaction with their child’s health care, disclosure of important psychosocial issues, and adherence. 11-14 A partnership-building communication style is characterized by solici- tation of parents’ opinions and suggestions for their child’s care. 12 Characteristics of patients, providers, and healthcare settings have been shown to influence patient–provider communication in pediatric and adult populations. For example, studies of adults have found that female and minority physicians are more likely to use a partnership-building communication style than male and non-minority physicians. 7,15-17 Other research has in- dicated that, after adjusting for patient race/ethnicity, patients of higher socioeconomic status (SES) have more positive inter- actions with their providers compared with parents of lower SES. 18,19 Pediatric research also has shown that providers are more likely to engage older children in social communication during visits, which is associated with more partnership-building com- munication with parents. 11,20,21 The aim of the present study was to examine characteristics of families (poverty status, parent education), providers (race, sex, previous relationship with family), and healthcare settings (visit type, prac- tice type) as predictors of AA parents’ perceptions of pediatric providers’ partnership-building communication style. From the Center for Clinical and Community Research, Children’s National Medical Center, Washington, DC (I.H., S.M., J.J.); and Department of Health Policy and Management, Johns Hopkins University School of Public Health, Baltimore, MD (L.W.) Supported by National Center for Research Resources Grant K12 RR017613. The authors declare no conflicts of interest. 0022-3476/$ - see front matter. Copyright ª 2011 Mosby Inc. All rights reserved. 10.1016/j.jpeds.2011.01.067 AA African-American CHC Community health center FPL Federal poverty level SES Socioeconomic status 262

African-American Parents’ Perceptions of Partnership with their Child’s Primary Care Provider

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Page 1: African-American Parents’ Perceptions of Partnership with their Child’s Primary Care Provider

African-American Parents’ Perceptions of Partnership with their Child’sPrimary Care Provider

Ivor B. Horn, MD, MPH, Stephanie J. Mitchell, PhD, Jill G. Joseph, MD, PhD, and Lawrence S. Wissow, MD, MPH

Objective To identify family, provider, and healthcare setting characteristics associated with African-Americanparents’ perceptions of partnership with their child’s primary care provider.Study design Data were collected via a telephone survey of 425 African-American parents of 0- to 5-year-oldchildren who had presented for a health visit 1 to 2 weeks earlier at participating pediatric primary care practicesin Washington, DC. Parents’ perceptions of the level of partnership building by their child’s provider were assessedusing the Street Provider Communication Style instrument.ResultsMultivariate logistic regression models indicated that, after adjusting for other family and provider/settingcharacteristics, parents seen in community health centers were more likely to report high partnership buildingcompared with parents seen at private or hospital-based practices. Parents with at least a college educationand those who described their child’s provider’s race as ‘‘other’’ were most likely to report moderate partnershipbuilding.Conclusions Future studies should examine elements of care delivery at community health centers that may leadto better partnerships between parents and providers in private and hospital- based practice settings. (J Pediatr2011;159:262-7).

Mounting research indicates that, compared with white children, African-American (AA) children experience poorerhealth outcomes and less parental satisfaction with pediatric primary care, even after adjusting for access-relatedfactors such as insurance coverage.1-3 For example, AA children visit the emergency department for asthma-

related issues >3.5 times more often than white children.4 Middle-income AA children also are less likely than their white coun-terparts to schedule appointments for routine care when they want them,5 and less likely to be referred to a specialist by theirhealth care provider.3

Research in adult patients suggests that less participatory patient–provider communication is a modifiable contributor toracial health disparities.6-8 Minority patients may not express their symptoms well because of language barriers, low health lit-eracy and educational attainment, and lack of self-efficacy regarding healthcare.9 A provider may be less inclined to use a par-ticipatory communication style with minority patients if he or she holds racial biases or has limited awareness of cultural beliefsand expectations regarding disease and clinical care.8 On the other hand, there is some evidence indicating that a participatorycommunication style contributes to improved health outcomes and, in turn, reduces health disparities among AA adults.10

The few pediatric studies performed to date suggest that the quality of parent–provider communication contributes tominority children’s health outcomes through its influence on parents’ satisfaction with their child’s health care, disclosureof important psychosocial issues, and adherence.11-14 A partnership-building communication style is characterized by solici-tation of parents’ opinions and suggestions for their child’s care.12

Characteristics of patients, providers, and healthcare settings have been shown to influence patient–provider communicationin pediatric and adult populations. For example, studies of adults have found that female and minority physicians are morelikely to use a partnership-building communication style than male and non-minority physicians.7,15-17 Other research has in-dicated that, after adjusting for patient race/ethnicity, patients of higher socioeconomic status (SES) have more positive inter-actions with their providers compared with parents of lower SES.18,19 Pediatric research also has shown that providers are morelikely to engage older children in social communication during visits, which is associated with more partnership-building com-munication with parents.11,20,21

The aim of the present study was to examine characteristics of families (poverty status, parent education), providers (race,

From the Center for Clinical and Community Research,

sex, previous relationship with family), and healthcare settings (visit type, prac-tice type) as predictors of AA parents’ perceptions of pediatric providers’partnership-building communication style.

Children’s National Medical Center, Washington, DC(I.H., S.M., J.J.); and Department of Health Policy andManagement, Johns Hopkins University School of PublicHealth, Baltimore, MD (L.W.)

Supported by National Center for Research ResourcesGrant K12 RR017613. The authors declare no conflicts ofinterest.

0022-3476/$ - see front matter. Copyright ª 2011 Mosby Inc.

All rights reserved. 10.1016/j.jpeds.2011.01.067

AA African-American

CHC Community health center

FPL Federal poverty level

SES Socioeconomic status

262

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Vol. 159, No. 2 � August 2011

Methods

A telephone survey was conducted with a non-randomsample of 425 self-identified AA parents of children aged0 to 5 years recruited from 7 pediatric primary care sitesin Washington, DC between May 2004 and March 2006.Three recruitment sites were community health centers(CHCs), 3 were private practices, and 1 was a hospital-based primary care clinic.

Participation in the survey was limited to English-speakingparents. To reduce the likelihood of confounding effects,children with parents or grandparents born outside themainland United States (eg, Puerto Rico, Dominican Repub-lic, Africa) were excluded because of the possible differencesin interactions in medical settings based on ethnic back-ground and immigration status. In addition, parents ofchildren with special health care needs, previously identifiedbehavior problems, or illness requiring care bymore than onesubspecialist or ever requiring more than one hospitalizationwere excluded to prevent bias due to greater reliance on thehealthcare provider for discussion of medical, behavioral,and psychosocial issues.

The Children’s National Medical Center’s InstitutionalReview Board approved and monitored this study. Infor-mation sheets describing the study’s goal of learning moreabout how parents communicate with their child’s providerwere given to parents at the 7 recruitment sites by a desig-nated staff person or displayed in a prominent location.Parents interested in participating (n = 748) filled out aninformation sheet and placed it in a locked box. Researchassistants collected information sheets from each siteweekly. Parents were contacted by phone within 2 weeksof their healthcare visit to screen them for eligibility. Eligi-ble parents completed the 20- to 30-minute structuredtelephone interview. During the interview, verbal informedconsent was obtained, and the parents were instructed torespond based on their interaction with the provider atthe most recent visit that they attended with their child.Parents who completed the interview were mailed a $20gift card to a local retail store.

The primary outcome—parent perception of providercommunication style—was measured using the 3-itempartnership-building subscale of the instrument developedby Street et al13 to assess parents’ perceptions of physicians’communicative behavior. This instrument also assessesparents’ perception of providers’ informativeness and inter-personal sensitivity. The present analysis focused on partner-ship building to build on previous research in AApopulations examining the closely related construct of partic-ipatory communication style.7,17 The wording of items wasmodified slightly to be appropriate for well-child visits (ie,‘‘medical condition’’ and ‘‘health’’ were changed to ‘‘health/development’’). Participants responded to the items regard-ing their last health care visit (‘‘The doctor encouraged meto express my concerns and worries’’; ‘‘The doctor askedfor my opinion on what to do about my child’s health/devel-

opment’’; ‘‘The doctor asked for my thoughts about mychild’s health/development’’) on a 6-point Likert scale rang-ing from 1 for strongly disagree to 6 for strongly agree; thusscores could range from 3 to 18. The internal reliability in thissample was good (Cronbach’s a = 0.74).In terms of predictor variables, parent education and

household income were measured as indicators of familySES.19 Parents’ self-reported highest level of education wascategorized as less than a high school diploma, high schooldiploma, at least some college, and post-bachelor’s degree.Annual household income was reported on a 7-point ordinalscale from <$10 000 to$$100 000. Midpoint dollar amountswere used to represent family annual income,22 and the 2006Department of Health and Human Services Poverty Guide-lines23 were used to derive the appropriate poverty thresholdfor each family based on self-reported number of persons inthe household. Each family’s annual income was divided byits respective poverty threshold to calculate the percentageof poverty. The cutoff 150% of the federal poverty level(FPL), a common standard for Medicaid eligibility,24 wasused to create poverty status categories.Parents also were asked about several provider characteris-

tics. Parents indicated whether the provider’s race was white/Caucasian, black/AA, Asian/Pacific Islander, American Indian/Alaskan, Latino/Hispanic, or unknown. These responses werecombined into 3 categories: white/Caucasian, black/AA, andother. Parents also indicated whether the provider was maleor female. Finally, parentswere askedwhether or not their childhad seen this provider before (ie, had a previous relationship).The final set of predictor variables comprised healthcare

setting characteristics, including whether the visit occurredin a private practice, hospital, or CHC and whether it wasa regular (well) checkup or a sick visit (according to parentreport). Several family demographic characteristics alsowere included as covariates, including parents’ number ofbiological children, marital status (married/single), parentand child age (calculated from parent-reported dates ofbirth), and parent-reported child sex.

Data AnalysisFirst, descriptive statistics were generated for family andprovider/setting characteristics as well as for partnershipbuilding. Next, one-way analysis of variance and the c2

test were used to examine differences in each of the primarypredictor variables by partnership-building classification.The independent effects of significant family, provider,and healthcare setting characteristics on partnership build-ing were then tested by conducting 2 multinomial logisticregressions, with ‘‘high partnership building’’ and ‘‘moder-ate partnership building’’ as reference groups. This series ofmultivariate models estimated participants’ relative risk ofbeing classified in the reference groups as opposed to theother partnership-building categories depending on levelsof the predictor variables, entered simultaneously. All anal-yses were conducted using Stata version 11 (StataCorp,College Station, Texas).

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Results

Of the 748 parents who completed information sheets, 81%were successfully contacted to screen for eligibility. Of thosescreened, 78% were eligible for the study. A total of 425 of the472 eligible parents completed the telephone interview, fora response rate of 90%.

Characteristics of the families, providers, and healthcaresettings are summarized in Table I. The average parent agewas approximately 30 years (range, 0-63 years). The meannumber of biological children per parent was slightly over 2(range, 1-9), and the mean age of focal children was 24months (range, 0-167 months). Almost half of participatingfamilies had incomes below 150% of the FPL threshold, andapproximately half had more than a high school level ofeducation. Over half of parents reported their child’sprovider’s race as white/Caucasian, one-third black/AA, and15% other (8.5% Asian/Pacific Islander, 0.2% AmericanIndian/Alaskan, 0.2% latino/Hispanic, 6.4% unknown).Two-thirds of children had been seen for a well-child visit,and 41% were seen in a private practice, 36% in a hospital-based clinic, and 23% in a CHC.

Partnership building scores in this sample were negativelyskewed (mean � SD, 15.04 � 3.76), raising concerns aboutusing the continuous scores in our analysis, because each 1-point increment in score might not correspond to meaning-ful differences in parent perceptions of provider partnershipbuilding. Therefore, we assessed the distribution to createa categorical variable that captured the most variance in

Table I. Descriptive statistics for parent-reportedfamily, provider, and healthcare setting characteristics

Mean (SD) n (%)

Family characteristicsFamily poverty status <150% of FPL 186 (48.7)Parent education

< High school graduate 41 (9.7)High school graduate 163 (38.4)At least some college 184 (43.3)Post–bachelor’s 36 (8.5)

Parent age 29.7 (7.8)Marital status, married 128 (30.1)Number of children in family 2.3 (1.4)Child age, months 24.0 (22.5)Child female sex 211 (50.5)

Provider characteristicsProvider race

AA 140 (33.0)White 219 (51.7)Other 65 (15.3)

Provider female sex 356 (84.2)Previous relationship with provider, yes 289 (68.5)

Healthcare setting characteristicsPractice type

Private practice 176 (41.4)Hospital-based 152 (35.8)CHC 97 (22.8)

Visit type (well child) 291 (68.5)Partnership building

Low 128 (31.4)Moderate 116 (28.4)High 164 (40.2)

264

scores. A large number of participants with the max scoreof 18 were categorized as ‘‘high’’; lower scores were evenlydistributed into 2 distinct groups of sufficient size to allowfor statistical comparison. Those who disagreed with at leastone of the 3 items were categorized as ‘‘low,’’ and those whoagreed with any of the 3 statements or expressed less thanuniformly strong agreement were categorized as ‘‘moderate.’’This 3-level classification of partnership-building scoresseems more behaviorally meaningful, and there are signifi-cant differences in total partnership-building scores acrossthese groups (high [18.0 � 0] vs moderate [15.95 � 1.16]vs low [10.41 � 3.22]; F(2, 405) = 586.56; P < .001).Parents who were single/divorced and those who reported

incomes below 150% of the FPL were significantly morelikely to report high partnership building than their marriedand wealthier counterparts (Table II). Also, even thoughmost parents with a high school education or less reportedhigh partnership building, those who had attended somecollege or more were more likely to report moderatepartnership building. The group comparisons presented inTable III show that parents who saw providers who theyclassified as white or ‘‘other’’ race/ethnicity were morelikely to report high partnership building than parents whosaw AA providers. Also, parents seen at CHCs were morelikely to report high partnership building than those seenin hospital-based or private practices.Two multinomial logistic regression models with different

reference groups (high and moderate) were used to examinethe independent effects of family, provider, and healthcaresetting characteristics shown to have significant associationswith partnership building in bivariate analysis. These multi-variate models, shown in Table IV, suggest several nuanceddifferences among parents in the high, moderate, and lowpartnership-building groups. First, parents who attendedsome college were nearly 6 times more likely to report

Table II. Associations between family characteristicsand partnership-building classification

Partnership building

High Moderate Lowc2/FP

Family poverty status, n (%)<150% of FPL 86 (47.3) 42 (23.1) 54 (29.7) .01>150% of FPL 61 (32.6) 64 (34.2) 62 (33.2)

Parent education, n (%)< High school graduate 22 (53.7) 4 (9.8) 15 (36.6) <.001High school graduate 83 (52.2) 35 (22.0) 41 (25.8)College 55 (31.8) 61 (35.3) 57 (32.9)> College 3 (8.8) 16 (47.1) 15 (44.1)

Parent age, mean (SD) 28.6 (7.8) 30.1 (7.8) 30.7 (7.6) .06Marital status, n (%)

Married 34 (28.6) 42 (35.3) 43 (36.1) .01Single/divorced 130 (45.0) 74 (25.6) 85 (29.4)

Number of children infamily, mean (SD)

2.3 (1.3) 2.4 (1.5) 2.3 (1.4) .70

Child age, months,mean (SD)

25.9 (22.0) 23.5 (24.8) 22.4 (21.2) .41

Child sex, n (%)Female 82 (40.8) 61 (30.3) 58 (28.9) .58Male 80 (39.8) 54 (26.9) 67 (33.3)

Horn et al

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Table III. Associations between provider/settingcharacteristics and partnership-building classification

Partnership building

High Moderate Lowc2/F,P

Provider race, n (%)White 87 (40.7) 62 (29.0) 65 (30.4) .01AA 41 (31.3) 45 (34.4) 45 (34.4)Other 35 (56.5) 9 (14.5) 18 (29.0)

Provider sex, n (%)Female 139 (40.5) 95 (27.7) 109 (31.8) .66Male 24 (38.1) 21 (33.3) 18 (28.6)

Previous relationship, n (%)Yes 110 (39.6) 87 (31.3) 81 (29.1) .13No 53 (41.7) 28 (22.0) 46 (36.2)

Practice type, n (%)Private 43 (26.1) 56 (33.9) 66 (40.0) <.001Hospital 68 (45.3) 34 (22.7) 48 (32.0)CHC 53 (57.0) 26 (28.0) 14 (15.1)

Visit type, n (%)Sick 48 (36.9) 37 (28.5) 45 (34.6) .56Well 116 (41.7) 79 (28.4) 83 (29.9)

August 2011 ORIGINAL ARTICLES

moderate versus high partnership building, and parents whohad a post-bachelor’s educationwere >20 timesmore likely toreport moderate versus high partnership building. However,these more educated parents also were si-gnificantly morelikely than parents with less than a high school education toreport moderate versus low partnership building. Parentswho saw providers of the ‘‘other’’ race category wereapproximately half as likely to report moderate than highpartnership building (but no less likely to report low thanmoderate or high). Parents seen at private and hospital-based practices were 7 times and 4 times more likely,

Table IV. Family and provider/setting characteristics as pred

Moderate vs high,RR (95% CI) P

Family characteristicsPoverty status>150% of FPL Reference<150% of FPL 1.28 (0.65-2.55) .48

Parent education< High school graduate ReferenceHigh school graduate 2.18 (0.59-8.08) .25College 5.87 (1.51-22.76) .01> College 23.34 (3.54-154.05) .001

Marital statusMarried 0.93 (0.47-1.85) .84Single/divorced Reference

Provider/setting characteristicsProvider raceWhite ReferenceAA 1.07 (0.56-2.04) .84Other 0.39 (0.16-0.94) .04

Practice typePrivate 1.73 (0.76-3.95) .19Hospital 1.3 (0.63-2.65) .48CHC Reference

LR c2

Pseudo–R2

African-American Parents’ Perceptions of Partnership with their C

respectively, to report low partnership building than highpartnership building; similarly, parents seen in private orhospital-based practices were at least 3 times more likely toreport low partnership building than moderate partnershipbuilding.

Discussion

Overall, most of the AA parents in this study perceived thattheir child’s provider used what we characterized as a moder-ate or high level of partnership-building communication, butthis perception differed by family, provider and healthcaresetting characteristics. We identified 3 important factors con-tributing to parents’ perceptions of the level of partnershipbuilding of their child’s provider: parent level of education,provider race, and type of practice where the child receivedcare.Our finding that AA parents with higher levels of educa-

tion (some college or higher) were more likely than parentswith less education to report moderate levels of partnershipbuilding compared with high or low levels are in contrastto previous research that found that providers are more likelyto practice partnership building with patients with highereducational levels.19 Those studies were conducted in adultpopulations, however. A 2007 study by Rosenthal et al25

found that parents with lower literacy levels (a potentialmarker for education level) rated the quality of their relation-ship with their child’s provider more positively than didparents with higher literacy levels. The authors posited thatthese findings might reflect lower expectations regardingthe parent–provider relationship. An alternative consider-ation may be that although parents with lower levels of

ictors of partnership-building classification

Partnership-building

Low vs high,RR (95% CI) P

Low vs moderate,RR (95% CI) P

Reference Reference1.64 (0.82-3.26) .16 1.28 (0.61-2.66) .52

Reference Reference0.55 (0.23-1.32) .18 0.25 (0.06-1.01) .050.98 (0.38-2.55) .97 0.17 (0.04-0.69) .013.02 (0.59-15.39) .18 0.13 (0.02-0.67) .02

0.81 (0.41-1.59) .53 0.86 (0.44-1.72) .68Reference Reference

Reference Reference1.54 (0.80-2.94) .20 1.44 (0.75-2.76) .280.87 (0.42-1.81) .71 2.24 (0.85-5.91) .10

7.96 (3.16-20.06) <.001 4.60 (1.71-12.38) .0034.30 (1.94-9.55) <.001 3.32 (1.35-8.17) .01

Reference Reference70.67; P <.001

0.09

hild’s Primary Care Provider 265

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education appreciate being ‘‘asked,’’ as stated in the currentmeasure, more educated parents may have additional expec-tations of the provider that involve a more bidirectionalexchange not reflected in the Street instrument. Therefore,even though our findings and those of Rosenthal et al25

suggest a need for providers to have more cultural awarenessof the diversity of health care expectations within the AAcommunity, particularly across groups with different educa-tional experiences, future studies should explore parentexpectations of provider response to inquiries in their assess-ments of partnership building in more detail.

Our findings also suggest that, unlike studies of patient–provider communication in adult populations,7,17 therewere no significant differences in AA parents’ perceptionsof partnership building for AA versus white providers whenother family and healthcare setting characteristics were takeninto account. Previous research in pediatric settings has sim-ilarly shown that racial concordance is not a determining fac-tor in parent–provider relationships.26 Our findings furtherhighlight the importance of distinctions between predictorsof adult and child health disparities. Horn and Beal27 pro-posed a conceptual model that takes the important distinc-tions between these fields into consideration. Adult healthdisparities research may benefit from understanding the bar-riers that pediatric providers might have overcome in theirinteractions with parents in racially discordant relationships.

Our finding that parents were more likely to report highversus low partnership building if they attended a CHC thanif they attended a private practice or hospital is particularlyimportant because CHCs provide primary care to millionsof children in medically underserved communities through-out the nation.28 Studies have shown that the recent eco-nomic downturn has resulted in a large increase in thenumber of people seeking health care at CHCs.29 Althoughfunding for these centers has increased, a workforce needcontinues.30 Our research indicates that despite the chal-lenges that parents may experience in receiving care inCHCs due to lack of providers, parents who take their chil-dren to these CHCs perceive the providers as using a morepositive, partnership-building communication style, inde-pendent of other family and provider/setting characteris-tics.

Although this study contributes to the understanding ofhealth disparities in pediatric care, some limitations of the re-search must be acknowledged. First, this study is cross-sectional and nonexperimental, which precludes inferencesabout the causal directions of associations between family, pro-vider, and healthcare setting characteristics and parents’ per-ceptions of providers’ partnership-building communicationstyle. Second, we were unable to account for any shared vari-ance attributable to certain providers having seenmultiple par-ticipants. When developing the study protocol, providersrecognized that parents would bemaking statements about in-dividual provider interactions and thus would not want to beidentified in the study. Therefore, providers were not con-sented as study subjects. Consequently, provider characteristicsand other information related to the visit, except for site type,

266

were based on parent report. Thus, wemight have erroneouslyattributed cultural concordance to racial concordance if, for ex-ample, parents labeled African orWest Indian/Caribbean pro-viders as black/AA;however, to the bestof our knowledge, therewere no African or West Indian/Caribbean providers practic-ing at our recruitment sites. Similarly, our measure of partner-ship building was based solely on parents’ perceptions withouttaking into account perceptions of the child or provider. How-ever, because parents are primarily responsible for treatmentadherence, we considered their perceptions to be particularlyimportant for this investigation. In addition, the psychometricproperties of the Street parent–provider communication in-strument in AA populations are unknown, and validity and re-liability testing is an important direction for future research.Third, there may be other unmeasured provider/setting char-acteristics that predict partnership building, such as seeinga resident versus an attending pediatrician. However, differ-ences between resident and attending physicians’ communica-tion styles have not been examined empirically, and suchdifferences are not expected to explain the current findings re-garding practice type, because residents saw patients in 1 of the3 private practices and at the CHCs and hospital-based prac-tices. Finally, as in all community-based studies, findingsfrom this sample might not be generalizable to the larger pop-ulation, because they refer to a select groupof parentswhowerewilling to participate in this research.Our finding that parents perceive providers in CHCs to

have a more positive, partnership- building communicationstyle supports the need for future research to examine thecharacteristics of the CHC practice environment that pro-motes more positive parent–provider interactions that canbe applied to the private practice and hospital-based practicesettings. Future parent–provider communication researchalso should examine within-group differences to betterunderstand the diversity of parents’ communication expecta-tions, particularly those of underserved populations. Finally,this study supports previous communication research inpediatric populations indicating that racial concordancebetween the provider and parent does not play a significantrole in parents’ perceptions of partnership in their relation-ship with their child’s provider. Future research wouldbenefit from examining the differences in communicationin pediatric and adult healthcare settings to identify potentialareas for more targeted intervention. n

Submitted for publication Jun 8, 2010; last revision received Dec 22, 2010;

accepted Jan 31, 2011.

Reprint requests: Ivor B. Horn, MD, MPH, Center for Clinical and Community

Research, Children’s National Medical Center, 111 Michigan Ave NW,

Washington, DC 20010. E-mail: [email protected]

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